Expert clinician’s perspectives on environmental medicine and toxicant assessment in clinical practice
Environmental Health and Preventive Medicine volume 23, Article number: 19 (2018)
Most clinicians feel ill-equipped to assess or educate patients about toxicant exposures, and it is unclear how expert environmental medicine clinicians assess these exposures or treat exposure-related conditions. We aimed to explore expert clinicians’ perspectives on their practice of environmental medicine to determine the populations and toxicants that receive the most attention, identify how they deal with toxicant exposures and identify the challenges they face and where they obtain their knowledge.
A qualitative study involving semi-structured interviews with expert environmental clinicians in Australia and New Zealand was conducted. Interviews were recorded and transcribed, and themes were identified and collated until no new themes emerged.
Five dominant themes emerged from 16 interviews: (1) environmental medicine is a divided profession based on type of practice, patient cohort seen and attitudes towards nutrition and exposure sources; (2) clinical assessment of toxicant exposures is challenging; (3) the environmental exposure history is the most important clinical tool; (4) patients with environmental sensitivities are increasing, have unique phenotypes, are complex to treat and rarely regain full health; and (5) educational and clinical resources on environmental medicine are lacking.
Environmental medicine is divided between integrative clinicians and occupational and environmental physicians based on their practice dynamics. All clinicians face challenges in assessing toxicant loads, and an exposure history is seen as the most useful tool. Standardised exposure assessment tools have the potential to significantly advance the clinical practice of environmental medicine and expand its reach across other clinical disciplines.
Epidemiologic studies, breakthroughs in biomarker research and large biomonitoring studies have raised awareness of the impact of environmental exposures and their relationship to chronic illnesses. Yet, whilst most clinicians acknowledge that environmental toxicants affect human health and are frequently asked about exposures by their patients, a lack of environmental health training and standardised exposure assessment tools leaves most clinicians feeling ill-equipped to assess or educate patients about toxicant exposures and their consequences [1,2,3].
Expert environmental medicine (EM) physicians not only require skills in clinical medicine, they also require specialised knowledge about the impact of different toxicants on human health, exposure sources and dose estimation, the factors that influence inter-individual variation to toxicant exposures, interpretation of laboratory tests, measures to minimise toxicant exposures and interventions that treat different sequelae. EM therefore requires the integration of knowledge from diverse fields and the skills to apply this knowledge in a wide variety of circumstances, yet this skill set is poorly defined and it is unclear how experts apply their knowledge to the needs of their patients.
Whilst there are text books on occupational and environmental medicine [4, 5], to date, there has been very little literature on the clinical practice of EM and little qualitative research on environmental clinicians’ perspectives. To address this, we undertook a qualitative study of environmental physicians with the aim to determine the nature of EM practice and identify how expert EM clinicians deal with environmental toxicant exposures. We further aimed to determine where clinicians obtained their knowledge and skills, the populations and toxicants that receive the most attention and the challenges they face in order to inform the development of resources and tools that can be used by all clinicians.
A qualitative study was performed that involved a series of one-on-one, in-depth, semi-structured interviews with clinicians with an undergraduate degree in medicine who were identified as experts in the field of EM.
Potential participants were identified by contacting doctors (via phone and/or email) known to be prominent in the field of EM through their speaking at conferences, lecturing in postgraduate courses and membership to either the Australasian College of Nutritional and EM (ACNEM) or the Australasian Faculty of Occupational and EM (AFOEM), which are the only two Australian medical organisations with ‘EM’ in their title. Some of the participants were known to the researchers prior to commencement of the study through mutual participation in conferences. This was followed by a snowball recruitment campaign whereby participants were asked to identify further experts. In addition to contacting prominent individuals, doctors listed on the ACNEM and AFOEM websites were emailed and invited to participate. A follow-up phone call was made to those who responded to explain the nature of the research and invite their participation. All prospective participants were emailed a Project Information Statement and contacted to make an interview appointment. Clinicians were not compensated for their time.
A series of open-ended questions was developed by the authors to determine:
The nature of their EM practice
○ The type of diseases they treated
○ How much time they spent with patients
○ The cost of consultation and tests
○ The populations and toxicants they focus on
○ Their greatest successes and challenges
How they assess environmental exposures
○ The most effective tools they use
○ The type of tests they undertake and how they interpret them
Where EM clinicians obtained their knowledge
○ The institutions and associations to which they belonged
○ The journals, websites and books used
○ The educational and clinical resources used
Interviews were conducted via Skype audio by the first-named author during which the clinicians provided informed consent. There were no other participants present and no follow-up interviews. General questions (tell me about your practice) initiated the conversation, and open-ended questions were used to give the participant the freedom to explain their responses and identify new themes. The interviews were recorded and transcribed, and a preliminary analysis of the initial interviews suggested new questions for the next interviewee as specific themes became apparent. Recruitment of clinicians continued until saturation had been reached (no new themes emerged).
NVivo 11.3 software program was used to document specific themes within each interview, and these were analysed to identify dominant themes common across the entire cohort. The results were reported according to published guidelines for reporting qualitative research .
A total of 16 clinicians participated in the study: 11 integrative medical practitioners (six males and five females) and five male occupational and environmental physicians. Thirteen clinicians were based in Australia, and three integrative medical practitioners were based in New Zealand. The average length of EM practice was 20 years.
The themes that emerged from the data analysis were:
EM is a divided profession
Clinical assessment of toxicant exposures is challenging
The environmental exposure history is the most important clinical tool
Patients with environmental sensitivities are increasing, have unique phenotypes, are complex to treat and rarely regain full health
Educational and clinical resources on EM are lacking
Theme 1: EM is a divided profession
The strongest theme is that environmental medicine clinicians can be classified into two distinct groups: integrative medical practitioners (IPs) and occupational and environmental physicians (OEPs) based on the nature of their employment (patient versus corporate-centered), the patient populations dealt with, the type of diseases they see, the type of toxicants they were concerned about and their views on the role of nutrition and genetics in toxicant exposures. Comments from clinicians that illustrate the differences between IPs and OEPs are presented in Table 1.
The nature of employment between the two groups was quite distinct. The IPs were general medical practitioners (n = 9) and paediatricians (n = 2) who worked in private practice and averaged five or more patients per day. IPs were directly employed by the patient, and the average cost of an initial consultation was $AUS 421 (this varied from $280 to $630) and the average subsequent consultation cost was $AUS 269 (this varied from $150 to $360). In contrast, the OEPs received a salary from an employer as company physicians in the aviation, military, mining, oil, gas or manufacturing industries to assess and monitor workers’ health or as advisors in government departments or emergency physicians in hospitals or an agreed fee to conduct medico-legal work to assess causation or disability for insurance companies or workers’ compensation or motor vehicle accident claims.
The OEPs primarily deal with adult men with musculoskeletal disorders and diseases arising from occupational exposures to heavy metals, asbestos, coal dust, beryllium, pesticides or solvents such as benzene, diesel and isocyanates. In contrast, the IPs saw patients with chronic, complicated ill-defined conditions involving multiple systems characterised by long-term fatigue (chronic fatigue syndrome, multiple chemical sensitivity and fibromyalgia), allergy intolerances, digestive disorders and chronic autoimmune, metabolic and/or neurological conditions along with children with learning, developmental and behavioural issues and recurrent infections.
Whilst all clinicians agreed toxicants are harmful, there was a stark difference in the type of toxicants they were concerned about. OEPs were primarily concerned about acute and chronic exposures arising from the workplace or hobbies where linear dose-response relationships are well described. In contrast, the IPs were concerned about long-term exposure to low-level toxicants in food, the workplace and the home environment and their combined effects. The two groups also differed in their perspectives on nutrition. OEPs considered nutrition as fringe medicine, not related to toxicant exposure except for special cases such as mercury in fish, pesticides in fruit and contamination of food with lead dust. In contrast, all the IPs highlighted food as the most important source of toxicant exposure and as a treatment to build resilience.
Whilst all clinicians acknowledged that genetics was important, most of them did not do genetic testing. None of the OEPs conducted genetic testing due to the costs involved, clinical uncertainty, lack of knowledge on gene variants and the ethics involved in discriminating against people. In contrast, four of the IPs conducted genetic testing in a minority (5%) of their patients with chronic, idiopathic environmental sensitivities.
Theme 2: Clinical assessment of toxicant exposures is challenging
Comments that indicate the challenges in assessing toxicant exposures are presented in Table 2. IPs noted that EM requires long consultation times that limits the number of patients that can be seen, leading to long waiting lists and high costs, which are compounded by the costs of specialised laboratory tests not being covered by third-party reimbursement. Toxicant and other laboratory tests were also noted to be unreliable, unavailable and lacking standard clinical approaches.
The OEPs reported their most significant challenge with toxicant testing was the difficulty in establishing cause and effect. In contrast, many IPs undertook tests with uncertain clinical meaning such as hair mineral analysis, digestive stool analysis, organic acids test, provoked challenge urine test, food sensitivity tests, lymphocyte sensitivity test, liver detoxification profiles, tests for specialised inflammatory markers associated with biotoxin exposure and tests to detect persistent organic pollutants or tick-borne diseases.
Theme 3: The environmental exposure history is the most important clinical tool
It was agreed by all clinicians that the environmental exposure history is by far the most important clinical tool for assessing toxicant exposures. The average time clinicians spent taking an exposure history was 90 min although this varied from 1 to 3 h. Some clinicians used formal questionnaires, whilst others relied on patients’ responses to guide their questioning. Clinicians’ comments on the relevance and characteristics of an environmental exposure history are presented in Table 3.
The exposure history encompassed a variety of questions about the patient’s occupational, dietary, dental, drug, lifestyle, hobbies and place history. Whilst there were many similarities in the type of questions asked, the OEPs spent more time obtaining a detailed occupational history, whilst the IPs spent time obtaining a comprehensive dietary history. Place history was considered to be important by both groups; however, whilst the OEPs focused on occupational exposures from workplaces, IPs focused more on exposures to traffic-related air pollutants, pesticides and other toxicants from commuting, workplaces and homes.
Theme 4: Patients with environmental sensitivities are increasing, have unique phenotypes, are complex to treat and rarely regain full health
Where IPs treated patients with chronic idiopathic environmental sensitivities, OEPs were more likely to attribute symptoms to psychological factors on the basis that linear dose-response relationships could not explain their symptoms. Consequently, information about patients with environmental sensitivities was mostly derived from the IPs, and their comments are presented in Table 4.
Several IPs noticed a significant increase in the incidence and awareness of environmental sensitivities like allergies, chemical sensitivities, neurodevelopmental disorders in children and mould-related illnesses over the past 10 years and commented that these patients were more likely to have gene variants in methylation and detoxification enzymes or specific haplotypes (HLA DRB-1, HLA-DQ) that made them susceptible to mould toxins and gluten.
Patients with idiopathic, multi-morbid diseases including chronic fatigue syndrome, multiple chemical sensitivity and autism were said to be the most difficult to treat due to challenges in limiting their exposures to everyday toxicants and poor tolerance to treatment, resulting in few of these complex patients regaining full health.
Theme 5: Educational and clinical resources on EM are lacking
Clinicians’ comments on the lack of resources available on EM and the limitations in their training are listed in Table 5. Clinicians reported acquiring their knowledge on environmental toxicants over many years through many different sources which included formal postgraduate qualifications, online journals and websites, conferences and workshops, government organisations and institutes, collaboration with peers, discussions with patients and searches on PubMed and Google Scholar. Training also varied considerably across clinicians with no single resource or training program being recognised as comprehensive or an industry standard. All interviewed clinicians had an undergraduate medical degree and 12 had postgraduate qualifications, yet despite this training, it was acknowledged that EM is still an emerging field. Online journals and databases were seen as an important resource for most clinicians with Google Scholar, SNPedia and PubMed listed as the most useful. Local and international conferences conducted by the following associations or institutes were cited as a useful source of information: Australasian Faculty of Occupational and EM, Australasian College of Nutritional and EM, International Board of Clinical Metal Toxicology (The Netherlands), Australian College of Medical Nutrition, American Academy of EM (USA), Autism Research Institute (USA), Mindd Foundation (Australia), Clinical Education (UK) and the Institute of Functional Medicine (USA).
The websites and books mentioned by clinicians as useful resources in EM are listed in Tables 6 and 7, respectively. The OEPs focused on websites and textbooks relevant to occupational medicine and toxicology, whilst the IPs mentioned websites and textbooks dedicated to functional medicine and specific environmental hazards like mould and chemicals in consumer products. Peers, colleagues and patients were often mentioned as an important resource for information on EM. Numerous researchers and authors were mentioned as important sources of information along with government departments, laboratories and tertiary institutions.
EM is a divided profession
It appears that EM is divided between bottom-up patient-based approaches and top-down population-based approaches to medicine. This division is based on training and practice settings, which distinguish between specialists in integrative medicine (the IPs) and occupational and EM (the OEPs). These groups differ in the type of patients and the diseases they see, the type of toxicants they are concerned about, differences of opinion on the role of nutrition, and the type of pathology tests used.
The difference between the two groups may arise from their different education and practice dynamics. All of the IPs had studied nutritional medicine and were working from a bottom-up approach to assess and treat multi-morbid disease in the absence of clear evidence. These doctors were seeing susceptible individuals with chronic responses to low-dose exposures including women with idiopathic environmental sensitivities, patients with neurodegenerative disorders and children with neurodevelopmental disorders. In contrast, the OEPS all had formal training in occupational medicine and were employed by industry and insurance companies on a top-down approach with an emphasis on musculoskeletal disorders and occupational exposures to noise, asbestos, toxic metals, coal dust and various solvents in mostly adult male workers. These doctors considered linear dose-response relationships as the gold standard in establishing adverse health effects and were sceptical of patients with chemical sensitivities and ‘fringe’ doctors who use nutritional approaches and laboratory testing with uncertain clinical meaning.
Clinical assessment of toxicant exposures is challenging, and the exposure history is the most important clinical tool
Whilst these differences give an appearance of a divided profession, there were strong similarities across all clinicians including agreement that an exposure history is the most important clinical tool, that EM is an emerging science with few established experts and that chemical risk assessment is challenging in the absence of standardised data-collection tools or guidelines for toxicant testing. Thus, clinicians questioned the value of tests with uncertain accuracy and clinical significance and favoured taking an exposure history over toxicant testing despite the time this requires. Whilst the elements of an exposure history varied amongst clinicians, they generally included questions about the patient’s past and current occupation, hobbies, lifestyle factors, diet, dental record and drug history. Several IPs stressed the importance of place history and the patient’s working, school and living environments. Despite its importance to clinicians and environmental epidemiologists , most clinicians were not formally taught to take an exposure history, and this is consistent with a report that only 20% of US paediatricians received training in environmental history taking .
Patients with environmental sensitivities are increasing, have unique phenotypes, are complex to treat and rarely regain full health
Clinicians acknowledged that patients with environmental sensitivities often have unique phenotypes and that patients presenting with allergies (food and aeroallergens), neurodevelopment disorders and mould-related disorders appear to be increasing. This is consistent with evidence of an increase in the prevalence of allergic diseases [9,10,11,12,13], learning and behavioural disorders [14, 15] and mould-related disorders [16,17,18,19,20,21]. Clinicians also observed that these patients are more likely to seek help earlier on, are more informed about toxicants and are difficult to diagnose, complex to treat, and rarely regain full health. These observations are supported by a growing body of evidence on the complexities in diagnosing and treating patients with environmental intolerances such as chronic fatigue syndrome, multiple chemical sensitivity and systemic exertion intolerance disease, sensitivity-related illness, idiopathic environmental intolerances, fibromyalgia, electromagnetic hypersensitivity and sick building syndrome [22,23,24,25,26,27].
Educational and clinical resources on EM are lacking
Despite the interviewed doctors all having extensive training in fields such as clinical medicine, public health, epidemiology, nutrition and occupational medicine, many felt inadequate to call themselves ‘experts’ or ‘environmental physicians’. This stems from their realisation that toxicant exposure assessment requires knowledge of highly complex clinical domains from genetics, nutrition, geomedicine, microbiomics and exposomics, which are not widely taught or integrated into clinical practice. Furthermore, environmental practitioners must diagnose and provide medical and nonmedical management for environmental diseases, translate new research results into practice and make complex causal inferences .
The complexities of EM are compounded by the lack of widely established educational resources with clinicians being unable to identify any single resource or training program that provides the knowledge they feel they need to practice EM. Consequently, clinicians were left to navigate their own path to acquire EM knowledge using a collage of sources including journals, books, websites, conferences, webinars and discussions with peers and patients. Remarkably, only one medical journal was mentioned as a useful resource, which highlights the lack of information on EM in general medical journals.
The perspectives of clinicians working at the coalface of EM highlights the many challenges posed by EM including dealing with poorly defined multifactorial diseases, making assessments without standard assessment tools, interpreting lab investigation without comparative data or established cause-and-effect relationships and a lack of educational resources and defined education pathways. Perhaps the greatest challenge posed by EM is that most chronic diseases may be caused or exacerbated by environmental exposures, and thus, EM is relevant to all fields of medicine . There is therefore a need to inform all clinicians about toxicant exposures and adverse health effects and educate them about the factors that influence individual susceptibility to toxicant exposures. This may be achieved through the development of standardised environmental exposure surveys and other tools to assess, monitor and map exposures and their health effects. It will also require the inclusion of EM education in standard medical curricula and post-graduate training and the publishing of information about EM in general medical textbooks and medical journals, which is a need that has been voiced by numerous organisations and researchers over many decades [29,30,31,32,33,34,35,36,37].
Whilst this paper has identified clear themes, our research is limited by inherent limitations of qualitative research which include the biases we bring as clinician researchers who decide on the questions to ask and how responses are interpreted. The study population was also limited to Australia and New Zealand, and the finding of two distinct groups clearly arose from the organisations from which participants were recruited. Our findings therefore may not be representative of EM clinicians elsewhere, and we cannot be sure that the inclusion of additional participants from other sources would not have led to additional or different themes emerging.
EM is certainly a complex field that requires an integration of top-down and bottom-up approaches in order to understand potential sources of toxicant exposures and their health impacts, monitor and mitigate individual exposure profiles and risk factors and evaluate measures to minimise exposures and their effects. These tasks are not only relevant to all clinicians, they also require engagement from the wider community, including policy makers and individual citizens, and the tools to achieve this are becoming widely available to the community. There are now multiple community-led, citizen-science campaigns and ‘crowd-and-the-cloud’ projects enabling the general community to participate in scientific projects that monitor exposures to toxicants at a personal level [38,39,40], collect data on the occurrence of disease geographically , identify the sources and impact of different exposures and assess the efficacy of public health campaigns and individual treatment protocols and expand environmental health literacy . Such efforts will be greatly assisted through the development of standardised exposure tools that combine medical and exposure history data with biomarker information along with data from the growing number of environmental sensors. This has implications for all future clinicians, educators and patients and will change the way that EM is practiced in the future.
EM is relevant to all fields of medicine yet is currently divided between integrative medical practitioners using patient-centred approaches in private-practice settings and occupational and environmental physicians using public-health approaches in workplace settings. Clinicians practicing EM face challenges in assessing toxicant loads in the absence of comprehensive educational resources, definitive laboratory tests, established dose-response relationships or exposure history tools. Whilst there is widespread agreement that an exposure history is the most useful clinical tool for assessing toxicant exposures, there are no standardised assessment tools, and the development of such tools has the potential to significantly advance the clinical practice of EM and expand its reach across clinical disciplines. Engaging patients and the wider community has further potential to integrate knowledge about toxicant exposures, individual susceptibility, lifestyle and work choices and usher in a new era of personalised medicine that accounts for the impact of the environment on the health of populations and individuals.
Australasian College of Nutritional and Environmental Medicine
Australasian Faculty of Occupational and Environmental Medicine
Integrative medical practitioners
Occupational and environmental physicians
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The authors would like to acknowledge the Jacka Foundation for providing the first author with a PhD scholarship. We would also like to acknowledge the clinicians who generously donated their time to participate in this research.
NB has 15 years experience in naturopathy and acupuncture, has a graduate diploma in occupational health and safety and is the principal of the Australian College of Environmental Studies and a PhD candidate. MC is a registered general medical practitioner with more than 25 years experience and a professor at RMIT University.
Ethics approval and consent to participate
The study was approved by the RMIT University Human Research Ethics Committee BSEHAPP 25-15. Clinicians gave their informed consent in writing or audio.
The authors declare that they have no competing interests.
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Bijlsma, N., Cohen, M.M. Expert clinician’s perspectives on environmental medicine and toxicant assessment in clinical practice. Environ Health Prev Med 23, 19 (2018). https://doi.org/10.1186/s12199-018-0709-0